Partial mobilisation of the neurovascular bundle for ventral penile curvature correction: A proof-of-concept study

Background: To lift the neurovascular bundle (NVB) is a critical step during dorsal plications for ventral penile curvature correction. Indeed, this procedure may hesitate in nerves and vascular damage. Herein, we present a revolutionary approach of partial NVB mobilisation that avoids dissection among 10 and 2 o’clock positions decreasing the risk of injuring nerves and vessels. Methods: We assessed ventral penile curvature after penile degloving, marking the level of maximal bending. Bilateral para urethral incisions were made and the Buck’s fascia carefully mobilised from the tunica albuginea. The mobilisation of NVB was carried until 10 and 2 o’clock, avoiding the area between 10 and 2 o’clock positions, where nerves and vessels are more concentrated. The 10 and 2 o’clock positions correspond also to the dorsal edges of the two cavernosa cylinders, where plications are more effective. Penile straightening after surgery was defined as residual curvature less than 10 degrees. Results: Between 2016 and 2020, we have operated 33 men and 32 boys with ventral penile curvature. The severity of penile curvature was mid (<30 degrees) in 13 (20%) patients, moderate (30–60 degrees) in 33 (51%) patients, and severe (> 60 degrees) in 19 (29%) patients. Penile straight was achieved for all patients. We recorded three haematoma, three glans skin erosion, and one curvature recurrence after 13 months of follow-up. No patient reported erectile dysfunction. Conclusion: This proof-of-concept study shows that partial NVB mobilisation is technically easier and safer compared to complete NVB mobilisation, without compromising the success of surgery. Level of evidence: Not applicable

Skin erosion in deep brain stimulation procedures: Using the temporalis muscle to treat this complication – A technical note

Background: Skin erosion is a common complication after deep brain stimulator procedures. Despite being a relatively common event, there is no standard surgical technique or a widely accepted guideline for managing this kind of complication. Methods: We describe a case of cutaneous erosion in the connector’s site of deep brain stimulation case, surgically managed with anterior displacement of the connectors and overlapping and wrapping the connections within the temporal muscle. Results: Postoperatively, the patient did well and achieved complete resolution of the skin erosion, with no signs of infection or new skin lesions. Conclusion: This technique demonstrated to be effective in this case in the long-term follow-up.

Severe Lactational Mastitis With Complicated Wound Infection Caused by Streptococcus pyogenes

Introduction Puerperal mastitis, a complication occurring during the breastfeeding period, is often caused by Staphylococcus aureus. Here we report on severe streptococcal mastitis in a lactating breast, with subsequent invasive disease and wound healing problems. Main issue The 41-year-old woman (G2, P2) presented at 2 weeks postpartum to our hospital with painful swelling and reddening of the left breast, in addition to fever and malaise, and complained about a nipple fissure on the left breast. Previously, her 4-year-old son was treated for an acute otitis media and her husband experienced flu-like symptoms. Management Due to the severity of the symptoms, Clindamycin antibiotic treatment was initiated intravenously. Streptococcus pyogenes was isolated in the milk. This strain is commonly known to cause infections of the upper respiratory tract, skin, and soft tissue, but rarely mastitis. Furthermore, the participant developed invasive disease with abscess formation and skin erosion with a milk fistula. Special dressing was applied to promote wound healing. The participant continued breastfeeding well into the child’s 2nd year of life. Conclusion This rare form of complicated mastitis with invasive disease caused by Streptococcus pyogenes called for an interdisciplinary approach. We want to draw attention to other pathogens causing mastitis and to alert health care workers to promote hygiene in lactating women to prevent transmission.

Abstract 13461: Longitudinal Evolution of Epicardial Pacing Leads

Introduction: Implantation of epicardial pacing leads remains a well-known alternative to the standard transvenous approach in several situations. However, long-term data on the performance and safety of epicardial pacing leads remain scarce. Methods: We conducted a retrospective cohort study at a single tertiary center including all patients with right or left ventricular epicardial lead implantation between 1996 to 2018; n=255. Electrophysiological lead parameters at implantation and during follow-up were analyzed and compared with clinical data from the electronic medical records. Results: 230 patients were included in the analysis. Implanted lead models included the Medtronic 4968 (n=202) and Medtronic 5071 (n=28). Indications for epicardial lead implantation included upgrade to CRT in 153/230 (67%) individuals and standard right or left ventricular pacing only in 76/230 (33%). Of the 153 epicardial CRT patients, 50 had a history of failed transvenous CRT and 103 had concomitant cardiac surgery for other indications and were thought to have a likely indication for CRT in the nearby future. Mean follow-up time was 4,7years±4,2. Lead impedances were significantly higher in the 4968 model compared to the 5071. Pacing thresholds for both lead models were similar at implantation but were subsequently significant higher in the 5071 model. Higher pacing thresholds in the 5071 model did not result in premature battery depletion. Periprocedural complications related to the epicardial lead insertion occurred in 3/230 patients. Epicardial lead related complications at follow-up remained low (8/230; 3 dysfunctions, 2 dislodgments, 1 impending skin erosion). There were only 2 cases of epicardial lead infections at follow-up requiring surgical extraction. 4,3% of all implanted leads remained unconnected at follow-up. Conclusions: Epicardial lead implantation for either CRT or pacing indications is a durable and safe alternative to transvenous lead insertion.

Off-label combination of leadless pacemakers and subcutaneous defibrillators in bilateral venous occlusion: a new reimplantation strategy after lead extraction

Background Subcutaneous implantable cardioverter-defibrillator (S-ICD) and leadless pacemakers (LPM) provide an alternative to transvenous implantable devices. Sometimes, after transvenous (TV) lead extraction, patients show a bilateral venous occlusion, resulting not eligible for TV reimplantation. Purpose This analysis was designed to provide preliminary data on feasibility and short-term outcome of an hybrid combination (Hyb) of s-ICD plus LPM after TV-ICD explantation, in patients without anatomical transvenous reimplantation options. Methods Among 2684 consecutive extracted patients, 31 (1.1%) were reimplanted with a LPM, 66 (2.4%) with a s-ICD and 6 (0.2%) patients with an Hyb combination. Hyb strategy was considered in patients with a pacing plus defibrillating indication, and an anatomical barrier, as bilateral superior venous occlusion or massive bilateral skin erosion. Results Hyb patients were old (72±10 years), with a prevalent ischemic disease (4/6) and a reduced ejection fraction (43±16%). Extraction indication was infection in 4 and severe venous occlusion in 2, and included 2 single chamber, 2 dual chamber and 2 biventricular ICD. After extraction, reimplantation timing was 7±6 days, LPM was implanted before and sICD the day after. LPM reimplantation indication was sinus node dysfunction in 2 and AV block in 4. Implantation duration was 68±23 and fluoroscopy time 9.4±2.3 min. ICD reimplantation indication was primary prevention in 4 and secondary prevention in 2. Implantation duration was 118±10 min. No complications were observed. At 1 year, no complications were observed, including device related cross-talks. Conclusions The Hyb strategy is a potential option after TV-ICD explantation in pacemaker dependent patients, when transvenous implantation is not available. Extraction and Reimplantation Session Funding Acknowledgement Type of funding source: None

Surgical treatment of spasticity: intrathecal baclofen pump implantation under subarachnoid block

Most patients with spasticity, rigidity, and other symptoms of the upper motor neuron syndrome respond effectively to surgical treatment with an intrathecal baclofen pump when their symptoms become intractable to nonsurgical measures. Baclofen administered into the lumbar subarachnoid space produces a locally high concentration at the spinal level and a low concentration supraspinally, avoiding most of the central side effects associated with a high oral dose, such as drowsiness and confusion.The aim of surgical treatment is to provide the appropriate volume and concentration of the drug in the subarachnoid space, avoiding the main surgical complications, that is, infections, skin erosion, and catheter displacement.The video can be found here: https://youtu.be/HetelPwwwak

Nonsurgical Management of an Exposed Deep Brain Stimulation Lead

Erosion of the skin overlying a deep brain stimulator (DBS) lead can occur in between 1 and 10% of cases. This complication increases the risk for subsequent infection, and full explantation of the lead is almost always necessary. In some specific cases, however, nonoperative management may be possible. This chapter describes a case of a patient with Parkinson disease (PD) and implantation of bilateral subthalamic nuclei (STN) DBS leads with a complicated postoperative course, requiring lead revision and extensive reprogramming to achieve therapeutic benefit. The patient later developed a skin erosion and eventual exposure of his brain lead, which recurred after skin graft placement. Because of the sterile appearance of his erosion and his willingness to be closely monitored, he was managed nonsurgically with only topical antibiotics. After 3 years of DBS therapy with an exposed lead, the erosion site became infected, requiring surgical movement of the system, but the patient experienced improved quality of life with DBS up until this point in time. Temporary nonoperative management of some low-infection-risk chronic lead erosions may be well-tolerated and allow for continued benefit from DBS. This conservative and controversial management choice may be helpful in rare cases in which a patient is benefiting greatly from DBS and would not be considered a candidate for DBS reimplantation.

Skin Erosion and Exteriorisation of a Cardiac Implantable Electronic Device: Modified Surgical Approach

Skin erosion and exteriorization of the commonest cardiac implantable electronic device (CIED) is usually caused by localized infection as a result of “pocket” infection. But, there are other recognized factors including an advanced age with thin, fragile skin with precarious subcutaneous fat. So, exteriorisation of a generator, and/or a lead, is not always associated with bacterial contamination followed by antibiotic therapy and contra-lateral re-implantation strategy. Hence, it does not always make the removal of the material an obligation. Our notable findings in a rare case of such exteriorization stimulate us to look for and implement a modified surgical technique. This 93-year-old extremely aged wonderfully co-operative, multi-morbid woman had multiple episodes of skin erosion and fixation, re-fixation surgery till the best result achieved. We present a new technique for cardiac pacing allowing for full patient recovery via an alternative surgical way of CIED relocation. J Bangladesh Coll Phys Surg 2020; 38(3): 155-157